What is the recommended treatment for eczema?

Treatment of Eczema

Start with regular emollients and topical corticosteroids applied no more than twice daily, using the least potent preparation that controls symptoms—most patients respond to this first-line approach without requiring specialist referral. 1, 2

First-Line Treatment Approach

Skin Care Foundation

• Apply emollients regularly after bathing to provide a surface lipid film that retards evaporative water loss 2, 3
• Use dispersible cream as a soap substitute instead of regular soaps and detergents that strip natural skin lipids 2, 3
• Avoid extreme temperatures and irritant clothing such as wool; cotton clothing is preferred 2, 3
• Keep nails short to minimize damage from scratching and reduce secondary infection risk 2, 3

Topical Corticosteroid Selection

Use the least potent preparation required to control symptoms, with the following evidence-based hierarchy: 1, 2

• Moderate-potency corticosteroids are more effective than mild (52% vs 34% treatment success; OR 2.07), particularly for moderate or severe eczema 4
• Potent corticosteroids are significantly more effective than mild (70% vs 39% treatment success; OR 3.71) for moderate to severe disease 4
• Very potent versus potent corticosteroids show uncertain benefit (OR 0.53, wide confidence interval), suggesting limited additional advantage 4
• For facial eczema specifically, use mild to moderate potency corticosteroids due to thinner skin and increased side effect risk 3

Application Frequency

Apply topical corticosteroids once daily rather than twice daily—this is equally effective for potent preparations and reduces unnecessary exposure 1, 2, 4

The evidence shows no difference in treatment success between once versus twice daily application (OR 0.97) in trials of potent corticosteroids lasting 2-6 weeks 4

Managing Secondary Infections

Bacterial Infections

• Flucloxacillin is first-line for Staphylococcus aureus, the most common pathogen 1, 2, 3
• Phenoxymethylpenicillin for β-hemolytic streptococci 1, 2, 3
• Erythromycin for penicillin allergy or flucloxacillin resistance 1, 2, 3

Viral Infections

• For eczema herpeticum, give oral acyclovir early in the disease course; use intravenous acyclovir in ill, feverish patients 1, 2, 3

Second-Line Treatment Options

Tar Preparations

• Ichthammol (1% in zinc ointment) is less irritant than coal tars and particularly useful for lichenified eczema 1, 2, 3
• Coal tar solution (1% in hydrocortisone ointment) is preferred to crude coal tar and does not cause systemic side effects unless used extravagantly 1, 2, 3

Antihistamines

• Use sedating antihistamines only at night during severe pruritic episodes as short-term adjuvants to topical treatment 1, 2, 3
• Non-sedating antihistamines have little to no value in eczema treatment 1, 2, 3
• Avoid daytime use; large doses may be required in children 1

Proactive (Weekend) Therapy to Prevent Flares

For patients with recurrent flares, apply topical corticosteroids twice weekly (weekend therapy) to previously affected areas—this reduces relapse risk from 58% to 25% (RR 0.43) 4

This proactive approach is supported by moderate-certainty evidence from trials lasting 16-20 weeks 4

Third-Line Treatment

Systemic Corticosteroids

Avoid systemic corticosteroids for maintenance treatment—they have only a limited role for occasional patients with severe atopic eczema after all other options are exhausted 1, 2, 3

The decision to use systemic steroids should never be taken lightly, particularly during acute crises 1

Phototherapy

Consider phototherapy for moderate to severe eczema not responding to first-line treatments, though concerns exist about long-term adverse effects including premature skin aging and cutaneous malignancies, particularly with PUVA 1, 3

Topical Calcineurin Inhibitors (Pimecrolimus)

• Use pimecrolimus only on areas with active eczema, not continuously for long periods 5
• Do not use in children under 2 years old 5
• Avoid on malignant or pre-malignant skin conditions, and in patients with Netherton's Syndrome 5
• Stop treatment when signs and symptoms (itching, rash, redness) resolve 5
• Patients should minimize sun exposure during treatment and avoid sun lamps, tanning beds, or UV light therapy 5

When to Refer to Specialist

Refer patients who fail to respond to first-line treatment, have extensive disease, or diagnostic uncertainty 2, 3

Most patients respond well to first-line management and do not require specialist referral 1, 2

Critical Safety Considerations

Skin Thinning Risk

Abnormal skin thinning occurs in only 1% of patients across trials (26 cases from 2266 participants), with most cases from higher-potency preparations (16 with very potent, 6 with potent, 2 with moderate, 2 with mild) 4

Pediatric Precautions

Use topical corticosteroids cautiously in children due to risk of pituitary-adrenal axis suppression and potential growth interference 1, 2

Patient Education Gap

72.5% of patients worry about using topical corticosteroids, with 24% admitting non-compliance due to these fears—the most common concern being skin thinning (34.5%), despite this being rare 6

Provide clear education about safety, potency, and appropriate use to address disproportionate fears relative to actual harm 6